| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
970 |
965 |
$91K |
| D1120 |
Prophylaxis - child |
1,639 |
1,634 |
$40K |
| D0274 |
Bitewings - four radiographic images |
352 |
351 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,167 |
1,164 |
$11K |
| D1206 |
Topical application of fluoride varnish |
1,709 |
1,706 |
$11K |
| D1351 |
Sealant - per tooth |
146 |
44 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
107 |
55 |
$5K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
171 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
101 |
98 |
$1K |